Wednesday, September 30, 2009

A paper has appeared in the J Clin Oncol comparing Bendamustine with Chlorambucil in untreated patients with CLL. It shows Bendamustine to be much better than Chlorambucil, but can we believe it?

The trial was conducted by a group of hospitals in Austria, Bulgaria, France, Germany, Italy, Spain, Sweden and the United Kingdom, though the names of the authors do not spring out as CLL experts apart from Marco Montillo from Milan. Very few if any of the patients came from the UK. The trial was funded by the manufactureres and marketers of Bendamustine. The statistics were designed by an outfit in Germany (DSH statistical services) with a record of designing trials in Homeopathy and the data were handled by Cephalon who market Bendamustine as Treanda in the US. In other words this was an industry trial. It is usual with industry trials for the drug manufacturer to pay the hospital participating a fairly large sum of money (perhaps 5000 Euros) for every patient recruited. Of course, I have no access to what financial arrangements were in place for this trial.

319 patients were randomly assigned to receive either Bendamustine or Chlorambucil (162 B, 157 C). The overall response rate was 68% for B and 31% for C. CRs were 31% for B and 2% for C. Median progression-free survival was 21.6 months for B and 8.3 months for C. As I said Bendamustine seems astonishingly better than Chlorambucil, though this does seem a very poor result with Chlorambucil, compared with say the LRF CLL4 trial.

Toxicity was worse with Bendamustine. Grade 3 or 4 adverse events occurred in 40% for B and 19% for C. This level of toxicity was regarded as acceptable.

This paper is published in JCO which probably means it was turned down by Blood. The criticism which any reviewer would have made would have been that the dose of chlorambucil was too low. They have answered this criticism by declaring that the dose of chlorambucil was equivalent to 60 mg/meter squared which compares well with comparisons with fludarabine (Rai = 40), alemtuzumab (Hillmen = 40) and FC (Catovsky = 70). That seems to be alright, but then I read the paper more carefully. The two drugs were given according to quite different formulae. Bendamustine was given in a dose of 100mg/sq meter for two days every 4 weeks, while Chlorambucil was given in a dose of 0.8 mg/kg for two days every two weeks. It seems strange that two different calculations were used and even stranger when I see that rather than weighing the patients they used something called Broca's normal weight. Now I had never heard of this so I Googled it. It turns out to be the height in centimetres minus 100. Does this give the same as weighing? By no means. I am 177cm high so my Broca weight is 77kg. Alas my scales make me 83 kg.

If I calculate the dose of chlorambucil I would have got under the LRF4 formula it would have been 143 mg, but under the Bendamustine paper formula it would have been 123 mg. I'm afraid my ideal weight is a little less than my actual weight. For my mother the discrepancy would have been even more. She is only 5ft 3, but weighs about the same as me. The Bendamustine paper would have given her 96 mg of Chlorambucil while the LRF4 calculation would have given her 139 mg.

So my original criticism stands - they seriously underdosed the Chlorambucil compared to what is optimum - just as the fludarabine and alemtuzumab trials did. Moreover they offer no description of modern prognostic markers - something I would regard as essential in a clinical trial in CLL. It may be that mutated and unmutated cases and del 11q and 17p cases were equally distributed among the two groups, but it may be that they weren't. This might be another explanation of why the Chlorambucil patients did so badly.

The introduction to this paper perpetuates the story that Bendamustine has both alkylating agent and purine analog activities. It is true that it bears superficial structural resemblances to a purine analog, but I have yet to see convincing evidence that it acts as one. I still believe that Bendamustine is just a way of getting adequate doses of an alkylating agent into a patient.

Tuesday, September 29, 2009

Last week a Northern Bottlenose Whale washed up dead on the beach at Bournemouth. It had been spotted swimming in the shallows for several days and the Press had named it Gilbert, but on September 22nd when it beached at Boscombe it was identified as a young female. It had not been feeding for several weeks at least. There are sharp net marks on the beak and tail but further checks need to be made to find the cause of death.

This is not the first time that a whale has died in the Bay here, but it is the first time in living memory. The last whale landed at Alum Chine in 1887. This was a much larger animal, being some 65 feet long. The local newspaper wrote 'Boys took running jumps up its slippery sides, and tobogganed down them on the seats of their trousers gleefully. Earnest schoolteachers took parties of youngsters and gave lessons in natural history. Farmers poked the thick hide of the beast with sticks, and inland folk raised exclamations of astonishment at its length, its strength and its thickness.'

Children also used to recite a rhyme, one version of which went as follows: Have you been to Boscombe? Have you seen the whale? Have you stood upon its back And smelt its stinking tail?

No-one really knew what to do with it and it was eventually auctioned and bought by a Dr Stockley for £29. He intended to exhibit the skeleton in a travelling road show. However it ended up on Boscombe Pier. It was displayed for several years, and often used as an impromptu slide by local children; the skeleton was eventually removed and ground down as fertiliser. Although no-one remembers it we have a written record and a photograph. The story is published on a poster on Boscombe pier. At the time it was regarded as a novelty; nobody then alive could remember it happening before.

Beached whales in Bournemouth are a once-in-a-lifetime event. I know there was one last week because I saw it and I know there was one 122 years ago because I've seen a photograph, and while you can PhotoShop pictures today you couldn't then. Then there is the written record. You can read it for yourself here.

This reference also refers to the records of Christchurch Priory, which dates from 1094. We have this record: On 13th October, Wednesday after the Feast of St. Denys, 8 Henry IV [ie the 8th years of the reign of Henry the Fourth = 1406], wreck occurred on the Earl of Salisbury's estate of Westover near la Bournemowthe [ie the mouth of the River Bourne], namely a great fish estimated to be 18 feet long, which was brought into the Earl's manor called Wyke [Wick] at Westover and there cut up into forty pieces.

A charter preserved among the records of Christchurch Priory reveals that in 1273 Isabella de Fortibus (then Lord of the Manor of Westover) made various gifts to the Priory, including: the right to dig 100 cartloads of turf a year for the Priory's kitchen, and two cartloads of heath daily for their brewery, from any part of her "field of Westestures". In addition to providing this fuel for the Priory, the heath of Westover was a major source of fuel for the inhabitants of the settlements along the banks of the River Stour. By ancient custom these people were entitled to take fuel from the heath for their own use - the common right of turbary [part of Bournemouth is known as Turbary Moor].

The Lord of the Manor of Westover was entitled to tithes of all fish caught, except of whales, of which he was entitled by ancient custom to the left fin. These rights had temporarily been assigned to Christchurch Priory by the then Lord, Isabella de Fortibus, in 1273. Anything that washed up on the beach was classed as "wreck", and this included not only driftwood but also the occasional whale. Wreck was the property of the Lord of the Manor (granted by royal charter as part of the Manor), but in practice appears to have been divided among the tenants.

This document is significant as the earliest known reference to Bournemouth - la Bournemowthe

This ancient document is 736 years old. There is only one copy. It has been preserved by Christian Monks. We find no reason to disbelieve it. The entry about the whale is later, being only 603 years old, but although it refers to an unlikely event, we still believe it.

How about this document: For what I received I passed on to you as of first importance: that Christ died for our sins according to the Scriptures, that he was buried, that he was raised on the third day according to the Scriptures, and that he appeared to Peter, and then to the Twelve. After that, he appeared to more than five hundred of the brothers at the same time, most of whom are still living, though some have fallen asleep. Then he appeared to James, then to all the apostles, and last of all he appeared to me also, as to one abnormally born.

This was written within 20 years of the events referred to and we have physical documents of the New Testament dating from 130 AD, some 80 years after it was written down. We have 8000 manuscripts of a Latin Translation and close to 5000 manuscripts in the original Greek. Compare that with our evidence of other pieces of history written about the same time. We have 10 manuscript copies of Julius Caesar's Gallic Wars, written after 58 BC and before 50 BC. The oldest of these manuscripts dates from 900 AD. In fact we have very few roman documents that date from before 900 AD - the oldest are the histories of Pliny the younger which are contemporaneous with the New Testament. We have 7 copies, the oldest of which dates from 850 AD.

Luke, a gentile historian writing at the same time as Pliny has been shown by modern scholarship to be an accurate and careful academic. He wrote: After his suffering, he showed himself to these men and gave many convincing proofs that he was alive. He appeared to them over a period of forty days and spoke about the kingdom of God.

and again: The priests and the captain of the temple guard and the Sadducees came up to Peter and John while they were speaking to the people. They were greatly disturbed because the apostles were teaching the people and proclaiming in Jesus the resurrection of the dead. They seized Peter and John, and because it was evening, they put them in jail until the next day. But many who heard the message believed, and the number of men grew to about five thousand.

and further: If we are being called to account today for an act of kindness shown to a cripple and are asked how he was healed, then know this, you and all the people of Israel: It is by the name of Jesus Christ of Nazareth, whom you crucified but whom God raised from the dead, that this man stands before you healed.

and finally: "What are we going to do with these men?" they asked. "Everybody living in Jerusalem knows they have done an outstanding miracle, and we cannot deny it. these men to speak no longer to anyone in this name."

What is truth? Some things happen so rarely that we doubt that they can happen at all. Whales washing up on English beaches or a group of black swans flying by are certainly unusual. Dead men coming back to life seems impossible to us, just as it must have been to Dr Luke. Nevertheless there were plenty of witnesses and there is a written record - transcribed when many of the witnesses were still alive.

As a historical record it is unimpeachable. As a legal witness statement it cannot be denied. The only reason for disbelieving it is that we can't conceive of how it could happen. I am not so arrogant as to believe that we know everything. What I can say is that the belief in a dead man walking has turned the world upside down.

Sunday, September 27, 2009

It is an accepted premise in medical research that following publication of a paper the data upon which the research was based upon should be available to the scientific community. It is seldom requested, but if the research is suspected to be fraudulant the raw data must be handed over and if none if forthcoming then the paper is condemned as fraud. One would hope that other areas of science would observe the same standards.

Let us examine anthropomorphic global warming.

In the early 1980s, U.S. Department of Energy funded scientists at the UK's University of East Anglia to establish a Climatic Research Unit to produce a comprehensive history of global surface temperature. The report by Phil Jones and Tom Wigley served as the primary reference standard for the U.N. Intergovernmental Panel on Climate Change (IPCC). It was this record that prompted the IPCC to claim a “discernible human influence on global climate.”

Putting together such a record is not straightforward. Long-standing weather stations were usually established at points of commerce, which tend to grow into cities that induce spurious warming trends in their records. Trees grow up around thermometers and lower the afternoon temperature. Further, many of the newer stations themselves are placed in locations, such as in parking lots or near heat vents, where artificially high temperatures are bound to be recorded. An overwhelming majority of stations are in the US and Western Europe.

It is perfectly legitimate for critics of the analysis to ask to see the raw data, but when Warwick Hughes, an Australian scientist, wrote asking to see the raw data he was met with a blunt refusal. Jones wrote to him, “We have 25 years or so invested in the work. Why should I make the data available to you, when your aim is to try and find something wrong with it?” It may have escaped Dr Jones's notice but the whole purpose of scientific investigation is to "try and find something wrong with it". If I made an observation that all swans are white and conducted my investigations only in Europe then all the evidence would agree with my hypothesis. Now as you know there are black swans in Australia. I could disprove my hypothesis by making observations in Australia, but supposing I refused to go there on teh grounds that making observations there might disprove my ideas.

In June 2009, Peter Webster from Georgia Tech told Canadian researcher Stephen McIntyre that he had requested raw data and Jones had freely given it him. So McIntyre promptly filed a Freedom of Information Act request for the same data. Despite having been invited by the National Academy of Sciences to present his analyses of millennial temperatures, McIntyre was told that he couldn’t have the data because he wasn’t an “academic.” So his colleague Ross McKitrick, an economist at the University of Guelph, asked for the data. He was turned down, too.

This sounds suspiciously like a conspiracy to deny people who disagreed with Jones any access to teh data. After turning down several requests from so-called 'climate change deniers' (which of course is itself a snide phrase, attempting to place such people in a group that includes holocaust deniers)Jones eventually had to respond to a request from Roger Pielke Jr, an esteemed professor of environmental studies at the University of Colorado. He received the following reply:

Since the 1980s, we have merged the data we have received into existing series or begun new ones, so it is impossible to say if all stations within a particular country or if all of an individual record should be freely available. Data storage availability in the 1980s meant that we were not able to keep the multiple sources for some sites, only the station series after adjustment for homogeneity issues. We, therefore, do not hold the original raw data but only the value-added (i.e., quality controlled and homogenized) data.

If data cannot be examined by independent adjudicators many people will assume that the data are unreliable.

Saturday, September 26, 2009

I disapprove of what you say, but I will defend to the death your right to say it.

This sentiment is attributed to Voltaire though he never actually said it (even in French). The nearest quotes are: "Think for yourselves and let others enjoy the privilege to do so too." and "Monsieur l'abbé, I detest what you write, but I would give my life to make it possible for you to continue to write."

It is a defence put forward by those who give room to unpopular or discredited views. Recently a film was shown at Cambridge University which propagated the discredited view that HIV does not cause AIDS. "Defence of free speech" screamed the organizers. Similarly, the BBC decided that the British National Party should be given time of British TV since many people voted for them at the European elections. It should be clear to everyone that the support for the BNP echoes their dislike of the European Union, but in no way endorses their racist policies.

So what position should rational people take of the free speech defence?

We do not allow racists to incite people to kill or attack black people, though we allow much more leeway to Islamists who encourage violence against Christians and Jews. We prosecute people who assert that the Bible opposes homosexual acts, yet we suspend police officers who decline to guard Gay Pride marches in which the marchers engage in acts of public indecency. Often our attitudes to censorship are colored by the political views of the government.

There are many instances where unpopular views have been censored by the church, or by government. Michael Servetus (whose 398th anniversary is on Tuesday), Galileo, Aung San Suu Kyi (incidentally did you know that it was the policy of the British Government to still call the country 'Burma' rather than 'Myanmar' because that is what the Democracy Movement there prefers?), William Tyndale and Gerry Adams are all people whose opinions were censored. Servetus and Tyndale paid the ultimate price for their opinions and so did Leon Trotsky. Censorship is surely preferable to assassination, and many would defend the silencing of Islamist preachers who have been the subject of 'control orders' by the British Government.

The libertarian view would be that we are grown ups and can decide for ourselves what we want to believe without the nanny state shutting people up. But what about those who are not grown up? Even libertarians will often endorse suppressing material aimed at children. Most people would want to restrict children's access to pornography and many would do the same for ultra-violent movies and computer games. Viewing child-pornography is regarded as a crime in many countries, principally because somewhere a child has been abused to produce the stuff. But how would the authorities regard Pixar-like cartoons of child pornography where every image was the figment of a warped imagination yet no child was harmed in its manufacture? Would it still be banned because of its tendency to incite?

There was a time when censorship of anything with a sexual content was routine. Bedroom scenes in movies were only passed by the censor if the actors kept one foot on the floor and even married couples always slept in separate beds. In Islamic countries similar standards are still applied. Yet we have become blase about watching advertisements with scantily-clad women (and men) much in evidence. The other day I visited the newly-restored Boscombe Pier. It sported photographs of the town at the beginning of the twentieth century. The clothes that women were required to wear when bathing at that time would astound viewers of Baywatch.

Cynics say that there is no such thing as bad publicity - getting your name in the papers is everything. Therefore when defenders of free speech publicise an unpopular view, intending to expose wrong-thinking to criticism, the 'wrong-thinkers' are delighted because some people will come out of the woodwork to agree with them and they are often able to misconstrue the public's response to them by lies and distortions. Benevolent liberals offer platforms in the interests of balance, but perhaps they would do better to be more judgemental. Discrimination has got a bad name, but we revere people with discriminating taste. Jesus said "Judge not that ye be not judged" but that text is usually taken out of context. We should certainly not be prejudicial, but elsewhere the Bible tells us to "test everything" and to "evaluate all things" and "choose between good and evil".

One of the great problems of denying free speech is in ensuring that you are not carried along by the popular view, just because it is the popular view and one endorsed by the the great organs of the press. I have made a study of scientific fraud and would no more agree with a point of view because "scientists have claimed..." any more that I would is "Barak Obama said..." or "Sarah Palin said...".

I admit to holding some unorthodox views myself. For example, I still think that there is a place for chlorambucil in the treatment of CLL. But I also have yet to see an adequate defence by Darwinists of how evolution escapes the rules of the Second Law of Thermodynamics or how they might come to terms with irreducible complexity. I find myself unconvinced by the idea anthropomorphic global warming. I am however convinced that the earth is not flat, nor is it travelling through space on the backs of four elephants supported by a giant turtle.

In science everything is contingent. Newton was correct until Einstein pointed out the exceptions. Our knowledge of the Universe is incomplete and science can never explain beauty, love, altruism, kindness, faith, harmony and self-sacrifice in anything other than descriptive terms. Stephen J Gould talked about different Magisteria; realms where science and religion held separate sway. I think he was right.

Friday, September 25, 2009

I have found a useful site for those who get spooked by newspaper headlines. It is called Behind the Headlines and is published by the NHS.

The latest information about Swine Flu in the UK is as follows.

•There are 218 people in hospital with swine flu, 25 of whom are in critical condition. •To date, 82 people with swine flu have died in the UK. There have been 70 deaths in England, nine in Scotland, two in Northern Ireland, and one in Wales. •There have been outbreaks in schools in 8 out of 10 regions in England.

The number of new swine flu cases has almost doubled in the past week, with an estimated 9,000 new cases.

Sir Liam Donaldson said, “Everything suggests that we’re starting to see a second wave to follow on from the July peak. We don’t know how big that wave is going to be, but we’re reaching the starting line.”

Approval for a UK swine flu vaccine is expected shortly, it has been announced. The recommendation has been made by the European Medicines Agency after carrying out an extensive review. The final decision will be made by the European Commission and is expected soon. The vaccine, Pandemrix, made by GlaxoSmithKline, is one of two vaccines being produced for the UK. The other vaccine being produced by Baxter is still under review. The two together will provide enough vaccine for the entire UK population. The European Medicines Agency is currently recommending that the vaccine be delivered in two doses, three weeks apart. However, it has acknowledged that there is initial data suggesting that one dose may be sufficient in adults.

The vaccine will be given to at-risk groups in the following order:

•People aged between six months and 65 years in the clinically at-risk groups for seasonal flu. •Pregnant women, subject to licensing by the European Medicines Agency, which will indicate whether it can be given throughout pregnancy or only at certain stages of pregnancy. •Household contacts of people with compromised immune systems. •People aged 65 and over in the current seasonal flu vaccine clinical at-risk groups.

As well as articles on swine flu, in the past week it has dealt with news items about a new and successful HIV vaccine, the question of whether it is dangerous to go into hospital when the new doctors are appointed, the MMR/autism debate, genetic clues to prostate cancer, vitamin D and skin cancer, a new drug for melanoma, HRT and lung cancer risk, whether people in a persistent vegetative state can think, and how much life you lose from smoking and drinking.

Many of these subjects are of interest to CLL patients, so I advise everybody to take a look.

Tuesday, September 22, 2009

The US spends around $7400 per person per year on healthcare, twice the health costs in Canada, the next highest spender. This increase is outstripping the nation's ability to pay. Over the past decade the rise in health spending has been more than 2 percentage points greater than GDP increases. If healthcare costs continue to grow at this rate, they will consume 150 per cent of the extra wealth that Americans would expect to gain as the economy grows between now and 2050.

In other words, as Americans get richer they will become poorer.

These are the conclusions of a new study published in Health AffairsIncreased Spending On Health Care: Long-Term Implications For The NationMichael E. Chernew, Richard A. Hirth and David M. Cutler

I would not presume to tell America how she should allocate health care, but when demand is greater than the ability to pay there has to be some drawing in of the belt. One way of looking at the problem is to regard health as any other commodity; some can afford Cadillacs and some get by with clunkers. If you want a better car you should get a better job and work harder. There are some drawbacks to this policy since we are protected from infectious diseases by herd immunity, but if the herd is already infected and there is no way in getting it immunized, then your only hope if you are unable to be immunized effectively (say you have CLL) is segregation. Many people do live in walled communities.

Restricting access to medicine by cost is how the free market would operate, but even in America the market is not free. I have just read an article on rationing of health care by a medical advisor on oncology to a medical insurance company (and sorry but I have lost the link). He takes the view that rationing is inevitable, but that it is far better that it should be explicit, so that potential patients can buy an appropriate product, than it should be implicit, which is what happens when the government gets involved.

If I were a member of a medical insurance scheme, I would be quite upset if my contributions went to pay for homeopathic medicine (indeed as a contributor through my taxes to the NHS I have been vociferous in my protests at the NHS funding homeopathic hospitals). Indeed, I would like things like IVF and breast enlargement excluded too. For the market to work properly, customers should have good quality access to good quality information about the product. When I buy a car or a television, I get the magazines devoted to these products like "What Car" and "What TV". I look at the features they offer, their performance, their size, and whether they are value for money. Then I shop around for the best deal I can get.

Most people don't shop for health insurance like that. Employers might, but they might also go for things like 'go-faster' stripes, that may look good, but don't add a whit to performance.

Of course, most of you won't be such an expert in health care as I am. Some of you will be able to read the original literature on which certain treatments are based, but even then access is restricted. Just getting access to some papers can cost $25 for each paper. But most of us have to rely on experts. Can you trust the experts? How many are in the pay of the pharmaceutical companies?

In the BMJ last week was a report of the International Congress Of Peer Review and Biomedical Publication in Vancouver. Of concern was the practice of senior academics having their names attached to papers written by pharmaceutical companies in order to give the paper 'authority'. It was asserted that more than 20% of medical articles had a "guest" author. Sometimes such articles were written by "ghosts" employed by the pharmaceutical companies for a fee, who spins the article so as to make a mildly interesting trial seem like a great discovery.

Plainly, the market in health care needs to be regulated. There need to be unbiased experts for are able to judge the merits of particular treatments to know whether they should be paid for or whether they are a waste of space.

Such a body exists in the UK in NICE. The problem with NICE is not its judgement on the efficacy of treatments - indeed it has been useful in telling us that certain well tried and trusted treatments that have been used for many years are of no earthly use - but in its attempts to put a price on anything. Far better for treatments to be evaluated on terms like the number needed to be treated to achieve a certain end and to give a broad range of the costs involved. For example, an average cost for administering a particular drug may be $x. Shop around and you might get it for $x/2. That would be a market with competition. Better still would be providers who could get a better deal from the drug company and market that - and be assured that such deals are available out there - I was able to negotiate them for drugs like neupogen. In fact it is routine to negotiate with pharmaceutical companies for different versions of NSAIDs or PPIs.

Here is an example of the complexity of decisions to be made. Some years ago I was consulted by a colleague about whether she should have adjuvant chemotherapy following her operation for breast cancer. When we consulted the meta-analysis of trials for her particular extent of disease it worked out that for every 20 women, chemotherapy would save two lives. For one in 20 it would not rescue her; she was doomed whatever we did and for the other 17 there would be no benefit, but they would have to suffer the complications of chemotherapy - hair loss, nausea and vomiting, and the possibility of an early menopause, cardiac damage, and later leukemia. A ten percent chance of a life being saved or you could look at it and say two thirds of those who would have otherwise have died of breast cancer would be saved. Or you could say that you needed to treat 10 women to save one life. Fine if it's an aspirin a day - not so fine if it is adriamycin - and Herceptin is not much different from adriamycin in its risk/benefit analysis.

See how difficult it is?

Rationing is bound to come whether Obama triumphs or not. Americans ought to be thinking now just how that rationing should be applied. Are we going to continue to buy the new biological therapies? The average annual sales growth in revenue for these was 20% between 2001 and 2006, compared to that of conventional drugs of only 6-8%. Some of these drugs may have too much patent protection in that they restrict biosimilar drugs from reaching the market.

Another strategy that might be applied is to have an excess on your policy of say $1000 as you might on car insurance so that the simple and trivial illness is dealt with at the local pharmacy, saving the doctor and expensive medicines for the real thing.

Obama's plan is a symptom not a cure. It tells us that trouble is on the way.

Thursday, September 17, 2009

My son David is a Formula 1 engineer. One of his friends, Pat Symonds has just resigned from the Renault Formula 1 team as a consequence of the cheating by that team in last year's Singapore Grand Prix. I don't suppose I need to detail the cheating episode, but for those who are unfamiliar with motor racing let us just say that Nelson Piquet junior deliberately crashed his car so that Alonso, his team mate, could win the race. Although no-one was injured, deliberately crashing a racing car is fraught with danger and they were extremely lucky that other drivers, track marshalls and spectators were not injured. Piquet has recently been canned by Renault and has turned whistle blower. By not contesting Piquet's allegations, Renault have virtually admitted that he is speaking the truth.

This is probably the most egregious example of cheating in any sport but I wonder what others make the top ten. The 'spear tackling' of Brian O'Driscoll by two New Zealand rugby players in the 2005 Lions' tour might well have broken his neck and did remove the Lions' best player from the tour. The 'hand of God' goal by Diego Maradonna during the 1986 soccer world cup that enabled Argentina to eliminate England in the quarter finals is number 1 with most Englishmen. Maradonna was not to blame, of course, the referee should have spotted the foul. You could hardly expect a sportsman to turn down a goal scored by cheating that the referee didn't spot.

The many years of testosterone that boosted East German Olympic medals is probably the most organized and efficient example of cheating in sport, while Ben Johnson's 100 metres gold medal in 1988 is probably the most famous.

The most disgusting example is undoubtedly the Spanish entry in the intellectually disabled basketball tournament at the 2000 Summer Paralympics. The team were morally disabled, not intellectually disabled. This cheat appears at number 10 in the top 10 sporting scandals but the others are mainly in American sports that most of the rest of the world don't play, but clearly there have been cheaters in basketball, baseball and American football. However even I have heard about shoeless Joe Jackson and the Black Sox. For the non-Americans, eight players from the Chicago White Sox were allegedly bribed by gamblers to throw the 1919 World Series to the Cincinnati Reds.

Tanya Harding, the ice skater, apparently arranged to have her ex-husband beat up her arch rival Nancy Kerrigan just prior to the 1994 US championships. However in the subsequent Winter Olympics, Kerrigan won the silver medal while Harding placed eighth. Another American, Rosie Ruiz, cheated to win both the New York and Boston Marathons in 1980. In New York, she apparently rode part of the race on the subway. Another ice skating controversy occurred when French and Russians judges colluded to give Russia's Yelena Berezhnaya and Anton Sikharulidze the gold medal at the Salt Lake City Winter Olympics.

Tommy Simpson, the British cyclist died during the 1967 Tour de France. He tested positive for performance enhancing drugs. Ever since there have been numerous rumors about cycling and drugs. At one American Society for Hematology meeting I attended a session on 'Sports Hematology'. It was when erythropoietin had just been made available. The lecturer hinted strongly that the American cycling team that won gold at the Los Angeles Olympics were on EPO. Certainly, the Tour de France has been plagued by accusations and in 1998 French officials caught an employee of the Festina cycling team with a carload of performance-enhancing drugs, including EPO. Following an arrest in the case, six of Festina's nine riders conceded they had used performance-enhancing drugs, including current Credit Agricole team leader Christophe Moreau. Later that year, he tested positive for anabolic steroids.

In early 2002, Italy's Stefano Garzelli, leader of the Vini Caldirola team, tested positive for traces of probenecid, a diuretic that can be used to mask other drugs, and Spanish cyclist Igor Gonzalez de Galdeano was banned from the 2003 Tour de France after a test during the 2002 event found excessive levels of an anti-asthma drug. Then there was Floyd Landis.

Polish-American sprinter Stella Walsh was one of the fastest women on the planet. Born Stanislawa Walasiewiczowna in 1911 in Poland, she moved to Cleveland with her family when she was two, but represented Poland at the 1932 and 1936 Olympic Games. She won the gold in the 100-metres in 1932, and silver four years later.

Walsh set 20 world records and won 41 American titles in events such as sprints, long jump and throwing the discus. In 1980 she was shot and killed outside a Cleveland shopping mall. Police autopsies revealed Walsh had male genitals and both male and female chromosomes - a condition known as mosaicism. Other 'female' athletes have had some form of intersex, including, it seems, the unfortunate South African runner who has featured very recently in the press.

Ball tampering is apparently rife in both cricket and baseball. Players have used emery boards or sand to rough up one side of a ball and Vaseline to shine up the other side. England captain Michael Atherton was caught with earth in his pocket, while pitcher Joe Nickro had an emery board in his. And have you ever wondered why Australian cricketers wear so much anti-sun tan grease on their faces? Pride of place should go to Gaylord Perry was notorious for using Vaseline on his pitches, so much so that he offered to endorse the product and even named his autobiography “Me and the Spitter.” Sportscasters would comment about how they had trouble seeing the field if enough foul balls from Perry’s pitches struck the window of the booth since there would be huge grease stains where the balls hit. But the worst cricket cheat was Hansie Cronje the former South Africa captain who stunned the cricket world in 2000 by admitting he had accepted about $130,000 from bookmakers to influence the course of matches. He was subsequently banned for life. Cronje died in a plane crash in 2002 aged just 32.

In soccer feigning injury and diving have become rife in professional sport. Croation-Brazilian, Eduardo was graded an impressive 5.8 for his swallow dive for a penalty kick for Arsenal against Glasgow Celtic. FIFA banned him for two games, but later let him off, it seems on the grounds that everybody is doing it.

Perhaps the saddest cheat was Donald Crowhurst who competed in the 1968 Sunday Times Golden Globe Race, an around the world yacht race. Crowhurst was notoriously ill-prepared for the race and it became quickly apparent that all would end in disaster. He quickly realized he faced the choice of either continuing and more than likely dying, or quitting and facing financial devastation. He chose option three, which involved hanging around the South Atlantic for awhile and making false radio reports about his location. Racked with guilt, he eventually committed suicide. His boat was found adrift, along with a 25,000 word log book that included false logs, poems, quotations, and a long philosophical treatise on the human condition.

One hardly knows where to begin with the use of drugs in athletics. It now appears that not only was Ben Johnson on drugs at the Soeul Olympics but so were those who were bumped up with his disqualification, Carl Lewis, Linford Christie and Dennis Mitchell. It seems most likely that FLo-Jo, who won the women's sprints was also on steroids. Following the BALCO scandal many people doubt that any successful athlete is clean.

Do you remember Russian pentathlete Boris Onishchenko who was sent home in disgrace from the 1976 Montreal Olympics? The Soviet Army Major was disqualified for hiding an electrical switch in his fencing sword which awarded him points when he had not in fact scored.

Recently there has been something of a scandal in Rugby Union, supposedly a hooligan game played by gentlemen. Well the famous Harlequins club bent the rules by feigning a 'blood' injury. The AIDS epidemic brought in a rule that meant that a player who is bleeding may leave the field temporarily while the cut is dealt with and be substituted by another player. Dean Richards, the Harlequins' coach has been banned for three years following a fake blood injury to gain an unfair advantage. Bit feigned injuries are getting commoner in rugby. A common ploy for a team being turned over in the scrums is for one of the props to feign injury. If there is no prop on the subs bench to replace him, then scrums become dangerous and must henceforth be uncontested. This gives the losing team an advantage since they may replace a lumbering prop by a nippy back row forward.

It seems that cheating is endemic. What is the point? I find that I am very good at crosswords if I turn to the back of the book and read the answers first. The Olympics seems to a competition between our chemists and their chemists, just as the space race was a competition between their Nazi engineers and our Nazi engineers. I any sport worth watching? Perhaps the competition should be about who can come up with the most innovative ways to cheat. Here are some suggestions.

Wednesday, September 16, 2009

The other day Labor minister John Denham issued a tirade against neo-fascist organizations in the UK, likening them to Oswald Mosley's blackshirts in the 1930s. I think this is prompted by the BBC's decision to give Nick Griffin a seat on Question Time, the BBC's flagship political discussion program. Here is a quote from the Guardian:

Announcing a government drive to address issues alienating white, working-class people at risk of being "exploited" by the far-right, John Denham, the secretary of state for communities and local government, singled out protests being organised by the English Defence League.

The group, has organised a number of protests in recent months which have turned violent. It is to hold events in Manchester, Leeds, London and Bristol in the coming weeks. Yesterday small groups of EDL supporters gathered for a protest outside a mosque in Harrow, north-west London. They were confronted by at least 1,000 anti-fascist protesters. Police arrested 10 people after clashes, nine of them for allegedly possessing weapons. No injuries were reported.

"I think the English Defence League and other organisations are not actually large numbers of people," Denham said. "They clearly though have among them people who know exactly what they're doing. If you look at the types of demonstrations they've organised … it looks pretty clear that it's a tactic designed to provoke and get a response, and hopefully create violence."

He pointed to historical "parallels" with Mosley's events. "You could go back to the 1930s if you wanted to – Cable Street and all of those types of things. The tactic of trying to provoke a response in the hope of causing wider violence and mayhem is long established on the far-right and among extremist groups."

The so-called Battle of Cable Street occurred in October 1936, when Mosley, the leader of the British Union of Fascists, attempted to lead his supporters through a Jewish area of the East End of London, leading to violent clashes.

In fact the supposed 'right-wing demonstration' had not been organized by the English Defence League, but by a different organization 'Stop Islamification of Europe'. And the demonstration reported by the Guardian, Reuters and much of the main stream media appears not to have taken place at all, though I can't be sure that a few skinheads and other thugs out for trouble didn't turn up. Here is the BBC report of the incident:

Stop Islamification of Europe (SIOE) said they planned a "peaceful protest" against the building of a five-storey mosque next to the Harrow Central Mosque.

But in a message on their website SIOE said the protest had been called off and organiser Stephen Gash had been arrested.

The posting read: "If you are on your way to the demo, don't go, it's being called off right now.

The police can't handle the Muslim counter-demonstrators. The senior sergeant said that he doesn't want any of his policemen killed."

Nine people remain in custody after being arrested for possession of offensive weapons including a hammer, a chisel and bottles of bleach.

Another person was arrested at the scene to prevent a breach of the peace, but he was released soon after, police said.

Police also stopped a number of people, who they believed were heading for the anti-Islamist protest, from getting to the protest area.

"If the SIOE demonstration started it would have resulted in serious disorder," a statement from police said.

If you want to know what really happened it is often useful to go to the local newspaper who probably sent a reporter to the incident - what appears in the nationals is often the result of Chinese whispers. This from the Harrow Times:

A DEMONSTRATION against fascism outside Harrow Central Mosque descend into violence and ugly scenes as groups of young Asian men ran amok through Wealdstone.

Despite earlier calls for calm and peace from community and mosque leaders, hundreds chased people through the streets around the mosque and got into scuffles with police.

On The Bridge, close to Harrow and Wealdstone station, the baying crowd of predominantly Asian young men pelted officers in riot gear with rocks, sticks, glass bottles and in some cases, fireworks.

After being forced down from the bridge, the men chased people through the streets and tried to storm Harrow Civic Centre.

With some peacemakers among the crowd, the protesters began turning on each other, leading to angry scuffles and confusion across the streets of Wealdstone.

The violence broke out as thousands, lead by Unite Against Fascism (UAF), turned out to opposed a planned demonstration outside the mosque by a group called Stop the Islamisation of Europe.

However, the right-wing group failed to materialised, and with tensions high among the anti-fascist protesters, it soon became clear violence was not far away.

A group of six white men were spotted heading from the station to the mosque at around 5pm, but before they could make their intentions clear, they were chased by dozens of the protesters, some armed with sticks, through the civic centre car park.

So who are the blackshirts now? The tactics adopted by these Muslim youths seem to be very similar to those of of Oswald Mosley, and while they may be no more representative of British Muslims than the original blackshirts were of the British working man in the 1930s, they certainly justify the tag, Islamofascists. Contrast their reaction to that of English Catholics four years ago when Muslims organized a protest outside Westminster Cathedral against something the Pope had said.

Much of this demonstration must have been very offensive to Catholics but there was no riot. I am afraid that this is the price that you have to pay for the privilege of free speech. People say things that offend you. That is why the BBC is right to allow the BNP to present their case. I believe the BNP to be a racist organization with simplistic solutions to complex problems. Under proper political scrutiny their defects will be come apparent. Likewise I believe that Islamofascists should be allowed to present their views to reasonable scrutiny. But if either group resorts to rioting or bullying or otherwise used violence, then the full weight of existing laws should be brought against them, without any fear or excessive sensitivity.

Tuesday, September 15, 2009

I have the reputation of being a bit of a pedant. I get annoyed by the misuse of English. Here are my top ten errors.

1 Pronouncing 'aitch' as if it began with one. 'Haitch' comes, I think, from Ireland where they have several idiosyncrasies in pronunciation - 't' for 'th' is a common one. 'Haitch' is now common among young people in the UK. Youngsters seem astonished when told it is a wrong pronunciation. Is school no longer compulsory in Britain?

2 The misuse of 'fulsome'. Praise is always fulsome. If only people knew what this really meant they would cringe with embarrassment. It is not a strong form of 'full'. In fact the word is derived from 'foul'. Fulsome praise is cloying, insincere, exaggerated, Uriah-Heap-like, praise. Sometimes when I hear the phrase I am not sure whether the user is being ironic.

3 Foetus. We English like our ligatures (not diphthongs, that's something else) in words like haematology, anaemia, oesophagus etc, but there are good etymological reasons for this. Take a word like 'aetiology' which Americans spell as 'etiology'. It sounds like it ought to be something to do with 'etiolate' but this has a quite different meaning and is 'etiolate' in British English too. But 'foetus' is a false etymology. It should be 'fetus' in British English also.

4 Apostrophes. In "Fish 'n' chip's" one of the apostrophe's is wrong. An apostrophe indicates that something has been left out. The 'n' is an abbreviated form of 'and' and therefore the apostrophes are correctly placed, but they have no place in a simple plural. In possessives, 'Archilbald's book' really stands for 'Archibald his book' though how that works for 'Mary's pencil' I'm not quite sure. The most irritating misuse is for the plural of a date. The 1970's is wrong and the 1970s is right. Please don't confuse 'its' with 'it's'.

5 Between you and I. Would you say 'between we'? Of course not! Perhaps this is a reaction against the equally incorrect "Me and my mate went to the pictures together." If so it is worse being not just ignorance but a misplaced elegant gentility.

7 'Anticipate' meaning 'expect'. This is what Fowler called 'slipshod extension'. If you anticipate something you do something about it beforehand. If you anticipate an attack by the Taliban, you forestall it, you don't just wait for it to happen. CS Lewis called this misuse of words 'verbicide'. Our vocabularies become impoverished unless we maintain distinctions.

8 Here is a battle already lost. 'Meticulous' is really a synonym of 'pernickety' rather than 'scrupulous'. It means more than taking a lot of care, it means doing so in a fussy and annoying way. Verbicide!

9 'Decimate' means to reduce by one tenth not reduce to one tenth. Not too bad if you win a war with 90% of your army intact, but to win with 90% dead would be something of a Pyrrhic victory.

10 'To claim' means to demand recognition of a right. Hence we have a claim that Humphrey Bogart, Walter Houston and Tim Holt fought over in "The Treasure of the Sierra Madre". It does not simply mean 'to assert'. Words are tools and like all tools it pays to keep their edges sharp.

It was just a routine out-patient appointment. My wife's vision had been deteriorating and we thought that a cataract was getting near to needing an operation. The conultant ophthalmologist took about 5 minutes to agree with us. My daughter's wedding is less than three weeks away so timing was critical. "I could do it this afternoon, " said the Consultant.

So this morning she is 18 hours post-op and seeing things brightly again.

Saturday, September 12, 2009

We are entering the flu vaccination period and I have been asked for advice for CLL patients.

The first thing to say is that CLL patients are very poor at responding to vaccines. If you have late disease and especially if you have been treated by a purine analog (Fludarabine, Cladribine or Pentastatin) of with Campath, it is very unlikely that you will respond to any vaccine. Your best hope of protection is to avoid infection - make sure that family members are vaccinated and avoid crowds (especially unvaccinated children). don't shake hands, don't share a common communion cup, avoid kissing unvaccinated people and wash your hands frequently. By all means get vaccinated but don't be too disappointed if it doesn't work.

As far as I can tell WHO advice (which dates from April 2009) still recommends that you have the seasonal flu vaccine.

This is the same as the 2008 vaccine, which many of you will have had, so having it this year boosts what is left of last year's immunity.

But since April 2009 we have had swine flu as a pandemic. This is also an H1N1 virus, but serologically different from the Brisbane virus present in the seasonal vaccine. It may be that it has similarities to the 1957-8 Asian flu pandemic since individuals over 65 do not seem to be suffering so severely from the new strain. Swine flu vaccines are being evaluated and should be available this month. The question is whether you will need both. The answer is we don't know. The recommendation, at least from the British Department of Health seems to be that one should have both, but I am not certain that experts have really addressed the issue. It really depends as to whether both strains of the virus will be infecting people this winter. From past experience it is the new strain that predominates.

Generally I advise CLL patients to have two flu shots at 6 week intervals and to take a big dose of ranitidine (300mg twice a day) for 90 days starting with the first injection. Whether this will work is still not established, but there are supporting papers for the idea. The imiquimod trial has not yet reported. I am not sure how to advise on what would potentially be 4 injections (2 seasonal, 2 swine).

Advice on pneumovax is very difficult. Response in CLL patients is virtually zero. This is because it is a polysaccharide vaccine to which CLL patients respond extremely poorly. In infants Prevnar 7 gives a better response (being a conjugated vaccine) and there is every reason to suspect that it would give a better response in CLL patients. However, it is designed for the 7 strains of pneumococcus that are present in 80% of infant pneumonias and may not cover as wide a range as the 23 strains in pneumovax. A Prevnar 13 is due out shortly, and in Europe a vaccine against 10 strains, Synflorix, is available. Again end stage patients and those who have had fludarabine are very unlikely to respond.

I'm sorry to be so uncertain, but that is the lie of the land at present. I will update this as time passes.

This from today's New Scientist: We expect medical therapies to undergo rigorous trials to ensure they are safe and effective. Yet we seem content to let our leaders conjure up policies based on what sounds good, rather than on what has been proved to work. The effectiveness of policies in many areas, from education and crime to reducing greenhouse gas emissions, can be empirically determined. As in medicine, the best evidence comes from randomised controlled trials; better still, a systematic review of multiple randomised trials.

As usual the doctors are decades ahead of the politicians. Over the years we have suffered form adopting policies in education, crime, public order, alcohol and tobacco use as well as other drugs' policy, and even military decisions that are based on people's opinions rather than evidence. Even worse is when public policy is based on a single anecdote that has been trumpeted in the Tabloid newspapers.

The nature of news is that it is so unusual as to catch the public eye. For example a few years ago a picture appeared in the pages of the BMJ of an X-ray showing a huge butcher's knife embedded in a person's skull; despite the horror of the picture, the patients survived unscathed. It was such a startling picture that it was incorporated into the story line of ER. Supposing public policy was based on that news story. An exception should be made to knife crime legislation because butchers knives inserted into skulls cause no lasting damage. Ridiculous, isn't it. Yet the plural of anecdote is not evidence.

Some years ago two little girls were murdered at a small Cambridgeshire village called Soham. Ian Huntly, their schools janitor was convicted of the murder and it was later established that Huntly had previously been investigated for but not charged in connection with one act of indecent assault, four acts of underage sex and three rapes. This information was unavailable to the school authorities when they appointed Huntley.

This horrific and obviously quite unusual case, triggered legislation that insisted that anyone appointed to a post which involved working with children must have a criminal records check which would uncover, not only crimes for which they were convicted, but also for which they had been arrested but not charged. For example, even though I do not treat children, the private hospital at which I did the occasional session insisted that I have a check on the off chance that I might encounter a child there. Scoutmasters, coach drivers, and Sunday school teachers all have to be checked and the government has recently extended the scope of the legislation so that even moms giving their kid's friends a lift to soccer training need to be checked. These checks cost about $50 and someone has to pay - I had to pay for my own check for the hospital. For every new activity a new check is required so for teaching Sunday School I had to be checked again. It has been estimated that one adult in 4 will need checking at a cost of about $250 million a year.

Had this been medicine NICE would have ruled it as unaffordable because 1 QALY would cost more than £30,000. The same would be true for crash barriers between carriageways on motorways (£1 million for every life saved) or the automated train warning system which stops trains passing through red lights (£3 million for every life saved). These systems may seem like a good idea, but they certainly aren't evidence based.

Friday, September 11, 2009

Yesterday was the 25th anniversary of the discovery of genetic fingerprinting. Despite the success of such shows as CSI, it was a British discovery. Alec Jeffreys had a "eureka moment" in his lab in Leicester after looking at the X-ray film image of a DNA experiment at 9:05 am on Monday 10 September 1984, which unexpectedly showed both similarities and differences in his technician's family's DNA. Within about half an hour, he realized the possible scope of DNA fingerprinting, which uses variations in the genetic code to identify individuals.

DNA fingerprinting was first used as a police forensic test to identify the rapist and killer of two teenagers, Lynda Mann and Dawn Ashworth, who were both murdered in Narborough, Leicestershire, in 1983 and 1986 respectively. Colin Pitchfork was identified and convicted of murder after samples taken from him matched semen samples taken from the two dead girls. In this case the chief suspect was eliminated and unsuspected Colin was pitchforked into the mire.

Alec Jeffreys is against the current British practice of including everybody on the database who has been arrested for a crime even if they have never been convicted. But then he was a hippie in his youth. You can see why the police want to keep all suspects on the database - often they are sure who did it, but they can't produce the evidence to substantiate their case. I am convinced that my every move is watched by a higher authority, so I shouldn't mind in the least having my DNA on a database.

Despite winning multiple prizes for his discoveries Jeffreys has yet to be enNobeled. Britain has a remarkable record in winning Nobel prizes with 117 awards (compared to America's 309 and Germany's 102). Of course America has a population of 307 million compared with the UK's 61 million and Germany's 82 million. Switzerland and Sweden have the best record at picking up Nobels per head of population; the Swiss with 3.57 per million and the Swedes with 3.11. Denmark is not far behind with 2.36. By the end of the century I would expect China and India to rank high on the list.

To revert to the British prizes; Among the discoveries of importance were monoclonal antibodies, antibiotics, DNA sequencing, protein structure, CT scanning, the structure of DNA, stem cells, MRI, the human genome sequence, beta blockers and H2 antagonists, NSAIDs, Pulsars, the structure of antibody molecules and the basis of organ transplantation.

Tuesday, September 08, 2009

I see that Samoa has switched over from driving on the right to driving on the left. It is the natural thing. Grooves in Roman roads show that the Romans drove their chariots on the left. It is said to be more convenient to have one's sword arm free to meet oncoming traffic. Research in 1969 by J. J. Leeming showed countries driving on the left have a lower collision rate than countries driving on the right. It has been suggested this is partly because humans are more commonly right-eye dominant than left-eye dominant. In left-hand traffic, the predominantly better-performing right eye is used to monitor oncoming traffic and the driver's wing mirror. In right-hand traffic, oncoming traffic and the driver's wing mirror are handled by the predominantly weaker left eye. In addition, it has been argued that left sided driving is safer for elderly people given the likelihood of them having visual attention deficits on the left side and the need at intersections to watch out for vehicles approaching on the near-side lane.

The reason that Samoa changed was to be able to import cheaper right-hand drive cars from nearby Australia and New Zealand. It is mostly former British colonies that continue to drive on the left, but notably, Japan and Indonesia drive on the left, perhaps this is why Japanese car firms have settled so easily in the UK - Nissan, Toyotaand Honda all have large factories here. The country with the largest population that drives on the left is India. The former Portuguese colony, Mozambique, drives on the left, even though Portugal switched to the right in 1928. Of former British colonies, Canada, Gambia, Ghana, Nigeria, Sierra Leone and the United States have all switched to right hand driving; Canada switched in 1923, but the USA changed sometime in the 1700s. It does not seem to have been under the influence of Napoleon, but because of the use of heavy waggons drawn by several teams of horses The Postilion sat on the left rearmost horse and preferred to have wagons passing him in the other direction go by on the left. Talking of Napoleon, in France, along the 350 metres (380 yd) of Avenue du Général Lemonnier in Paris, which connects the Pont Royal to the Rue de Rivoli, traffic drives on the left.

Iceland switched traffic from left to right at 06:00 on Sunday 26 May 1968; the only injury from the changeover was a boy on a bicycle who broke his leg

Control of driving side is often dictated by dictators or conquerors - Mussolini dictated that Italy should switch, Hitler changed both Czechoslovakia and Austria. Korea and Taiwan changed back when the Japanese left. Right-hand traffic was introduced in the Philippines on the last day of the Battle of Manila, 10 March 1945, to facilitate American troop movements. But Hong Kong has remained on the left since it became part of China. Burma (a former British colony now known there but almost nowhere else as Myanmar) switched in 1970 on the advice of a wizard. The US Virgin Islands (a former Danish colony) drive on the left as do the US Sovereign bases in the UK.

Oh and the standard gauge on British railways of 4 feet 7 inches was determined as the width of two horses backsides.

Monday, September 07, 2009

Therefore rid yourself of all malice and all deceit, hypocrisy, envy, and slander of every kind. Like newborn babies, crave pure spiritual milk, so that by it you may grow up in your salvation, now that you have tasted that the Lord is good.

What is the 'therefore' there for? Because of the word that was preached to you. What was that word? That you have been born again.

Born again is such a cliche. It seems that everyone is claiming to be born again. But is this rebirth real? It is not just turning over a new leaf. It is not just a new year's resolution. It is not just a determination to try and do better. We have all been there and know how futile those resolutions are. Being born again is about letting go of your old life. There may have some things in your old life you were proud of: those exams you passed, those scout badges you won, that time you were top of the class in maths, that good deed you did for your neighbor; you can't retain any of that. Count them all as dirty rags.

You have to be born again. Nothing of the old life has to be clung on to. If you were a mullah of the Islamic faith or a Hindu priest, or twirled your Buddhist prayer wheel for decades; if you were a graduate of the finest theological department in America, or a tyro at philosophy; if you graduated at the top of your class; if you were famous in your field; none of it counts. A newborn baby has no use for its placenta. For nine months it has received nourishment and oxygen through the placenta, but now it must receive its nourishment from milk and its oxygen through its lungs. The placenta is no use to it now. So we must free ourselves from our previous lives.

It is easy to say we should be free of malice and all deceit, hypocrisy, envy, and slander of every kind, but that doesn't mean we can retain our half-decent behavior towards the neighbors, our odd acts of kindness, our love for our parents and spouse, our unwillingness to kick a dog, our charitable gifts to starving African children, and rack them up as credit to our account. All our righteousness is as dirty rags.

There is a reason for this. We must never think that we save ourselves. If we consider ourselves as the Elect, soon enough we get to thinking why we were chosen. Was it because we are better looking, better behaved, more intelligent, less depraved, had better genes, because we were Anglo-Saxon or had some Jewish blood? No, none of those things. God loves us because He loves us. It is a mystery why. Too many people have become puffed up because they thought themselves special. There is a song that goes "I'm special because God loves me". I can't sing it; I don't think of myself as special. Certainly, I think of myself as blessed and loved, but it's not my just deserts. Even if we recognize that salvation is all of God we are apt to think that salvation was offered to the whole world but only some accept the offer. Then we praise ourselves for our perceptiveness in accepting the offer. We forget that faith itself is a gift of God.

So like newborns we must put aside all those remnants of our former state. Malice is the bad feelings we have against other people. Most commonly this manifests itself as hatred of people who are not like us. Black people can hate white people and white people can despise black people. The racism industry defines racism as malice of the oppressor against the oppressed when the oppressed is of a different color. Sexism is always of the man against the woman. Homophobia is specifically or the straight against the gay. We don't have a word for the gay man who hates the straight man. But malice is not unidirectional - it cuts both ways. In Africa we see different tribes killing each other for no reason except that they are of a different tribe. We are all guilty of tribalism. In Afghanistan we get worked up here about British soldiers dying. Other deaths hardly merit a headline. We might read of American or Canadians dying, but these deaths occur below the fold, and if a Dane or a German is killed, it doesn't even make page 17. As for Afghans dying it is sometimes greeted with glee - serves 'em right. This is malice.

I saw today that 70% of Britons don't think it is wrong to steal from work. Pencils, paper, various bits of office supplies, the odd front wing from the car factory, free rides on the train, they're all the perks of the job. Not only do we deceive our employers, we deceive ourselves. This is theft. Deceit is a way of life for many people. They lie to their boss, they lie to their wives, they lie to the police, they lie to their customers. I read somewhere that Islam demands that you must always be honest to another Muslim - you may deceive the infidel, of course. But we must put away deceit. Let your yes be yes and your no, no.

Hypocrisy in Greek refers to being an actor. Pretending to be what you're not. Do you ever say what you think your audience wants to hear rather that what you believe to be true? You are being a hypocrite. Hypocrisy is what Christians are accused of more than any other sin. It means taking off your Sunday attitudes with your Sunday suits and living through the week in your dirty rags. How shaming that Christians should have this reputation!

Envy is a green eyed monster. It isn't the same as jealousy. Our God is a jealous God. Jealousy is about asserting our right to what is ours, envy is about desiring what is not ours. The ten commandments talk about coveting. Nowadays we talk about keeping up with the Jones's. Sometimes it seems that our whole economy is based on envy. People get into terrible debt because they want what other people have. When I was young, we only bought what we could afford to pay for. It was years before we had a television or a vacuum cleaner, or a washing machine or a dishwasher. We waited until we could afford them. Now we have the government encouraging us to use our credit cards or to borrow money to buy new models. They have pumped money into the economy but are cross that people are using it to pay of their debts. We are about to see my younger daughter married. I was dumbfounded when I heard of the cost of weddings. Someone I heard of organized a fly-past of some aerobatics flight. I told my daughter to give everybody a plain sheet of paper and we could have a competition for who could make the best paper airplane. Those could be our fly-past.

What does it benefit us to acquire a bigger and better flat TV screen - next year our neighbors will have bigger and better ones. I'm quite proud of my 10-year old car - may it last as long as I do.

Slander isn't just the civil offence that we might be sued for. It means saying unkind and unfounded things about people. My mother told me that If I couldn't think of anything nice to say about someone, I should keep my trap shut. It is so easy to make subtle insinuations about people, especially your rivals or opponents. Notice it talks about slander of every kind. It's not just the things we might be sent to prison for, but subtle hints.

When we talk about putting away all these evils, we are too apt to think in terms of great crimes. If we have never appeared in a court of law, we think we are all right. If we are a little bit better than the Smiths across the street, we think we are doing well. But the Smiths aren't the standard we have to live up to, Jesus is.

I emphasize, we are not trying to justify ourselves, but having been justified by Christ we are allowing the Holy Spirit to work out our salvation within us. I have written before about the Matthew Parris article in the Times at the end of last year in which he, an atheist, said that what Africa need is not aid, but a change in heart. What Europe needs, what America needs, is not their finances sorted out nor an end to the recession, but a change in heart.

We need to rid ourselves of the things that characterized our former life - not necessarily great things like murder or theft or rape - but the silent sins that few know anything about: addiction to porn, love of money, spousal neglect, a nasty temper, a cynical attitude, pride of life, addiction to chocolate, overeating, spiteful attitudes to others, self-centeredness, gossiping (did you know that gossiping is listed with homosexual acts as something to be avoided), neglect of our parents (even if they are difficult), lack of generosity, insincere creeping around the boss, excessive patriotism, little acts of sabotage, even stealing paperclips. Do you justify watching late-night programs by stressing their social context and claiming you ignore the overtly sexual scenes? Do you watch movies replete with four letter words without protest claiming that that is how life is? Do you exceed the speed limit because 'everybody does it'?

We can be sailing along in our lives with everything going swimmingly. We seem to have a fair wind behind us, the business is going well, the wife is apparently happy, the kids are in good schools, our church is successful with large congregations and a healthy building fund, but all the time we are nursing secret sins. The communion service tells us that a man ought to examine himself. But that self examination should be part of our keeping short accounts with God.

We should crave pure spiritual milk. Where do we get it? Most importantly from the Word of God. There are many means of grace - prayer, fellowship with other believers, reading Christian books, the communion service - but we are fed from the Word and by the Word faithfully preached. We should be careful that the preaching we are sitting under is faithful to Scripture. We don't need our ears tickled about politics or sociology. We don't need Pollyanna. We don't need a lesson in New Testament Greek or journeys through Assyrian history. The Scripture can be hard to understand (though the hard part about it is more often putting it into practice) and that is why the Lord has raise up preachers to faithfully expound the Word to us. They are worthy of double honor, but woe betide any preacher who leads the faithful astray. It is an awesome responsibility.

One final word. Chapter 2 verse 3 says, "Now that you have tasted that the Lord is good."I worried about that word 'tasted'. Then I remembered. Hebrews 6:4-6 "It is impossible for those who have once been enlightened, who have tasted the heavenly gift, who have shared in the Holy Spirit, who have tasted the goodness of the word of God and the powers of the coming age, if they fall away, to be brought back to repentance, because to their loss they are crucifying the Son of God all over again and subjecting him to public disgrace." Are we babies or miscarriages? The parable of the sower is clear that the seed sometimes falls where the soil is thin. It may spring up rapidly but without rooting itself properly it withers and dies. We may talk about once saved; always saved but the question is are we truly newborns or just abortions. To be sure we must take the spiritual milk and digest it.

Saturday, September 05, 2009

Gordon Brown is in trouble again. His justification for British troops dying in Afghanistan did not go down very well with the public.

Although there is tremendous support for our soldiers there is precious little for our political leaders who sent them there. Now is the time to reassess what we are doing there.

Our original mission was to go after Bin Laden who was being given shelter there by the Taliban. Lest anyone doubt it, the Taliban, whose aid the CIA recruited to get rid of the Russians, ran an atrocious regime. The Taliban were deposed and Bin Laden driven out of Afghanistan, but he and they took up refuge in the mountainous frontier territory between Pakistan and Afghanistan. From there they have broadcast propaganda and influenced extremist Wahibi-style Islamist attacks wherever Western influence is strong. Incursions into Pakistan have invoked a strong reply from the Pakistani government.

However, the Afghan government is unpopular and corrupt. It almost certainly earns a lot of heroin dollars and the recent 'election' was a farce. Attempts to establish the sort of government that we would approve of seem doomed to failure. We would like to see a country where free and fair elections took place, where women were treated equally with men so that young girls could get an education, where an infrastructure could be constructed by civil engineers and where poverty was eliminated. I am afraid it ain't going to happen.

The most recent propaganda setback, the bombing of the two stolen petrol tankers shows why. Around 90 people were casualties - it is not clear whether these were all killed or if some were 'just' severely injured. Reports suggest that 60 Taliban were killed and that among the civilians were many who were stealing the gas. But probably some innocent spectators were also killed. The children mentioned in early reports were probably not killed but badly burnt by the explosion.

The Afghan government protests against the killing of civilians, though who is a civilian in this war is hard to find out. Best estimates suggest that 60% of civilians are killed by the Taliban and 40% by NATO. This type of asymmetric war is won in the newspapers not the battlefield. The sort of carpet bombing that the US carried out at the start of the campaign could not be envisioned now because of civilian casualties. The number of NATO deaths is very small compared with previous conflicts. The American civil war remains the war that killed most American soldiers and the butcher's bill for World War One makes the Afghan campaign seem like a minor traffic accident. Nevertheless, each man's death diminishes me. WWI would not have lasted 4 years had it been televized. We now see the grief of every bereaved parent and none of us can stand it.

Predator bombing has been successful in killing Taliban, but inevitably kills civilians. It is said that in order to 'win hearts and minds' the killing of civilians must stop. Strange that this consideration does not deter the Taliban - or indeed the various factions in Iraq.

Our desire to construct a liberal regime in Afghanistan is doomed. When we've finished there do we intend to do the same in Saudi Arabia, Kuwait, Zimbabwe, the Yemen, Somalia, China, North Korea, Russia, Belarus, Uzbekistan, Kazakhstan, Nepal, the Congo and probably most other nations in the world? There are those who would say that reform is necessary almost everywhere else including parts of the US and EU. So why are we still in Afghanistan? Principally it is to guarantee that Islamist terrorists don't attack our cities again. One option for NATO would be to talk to the Afghans from all parties and say, "You don't want us here, and as sure as night follows day we don't want to be here. If you agree not to harbor terrorists we will leave and you can run your country how you please. But the first time any terrorist act emanates from your country we will bomb you back to the stone age and we won't care how many civilians are wiped out. It is your responsibility to ensure that we are not attacked. We have offered you civilization and you have rejected it. On your heads be it."

I'm not saying that I favor this approach, but I would like to hear the arguments against it.

Friday, September 04, 2009

It is widely believed that the United States has eclipsed Europe in pharmaceutical research productivity. Indeed the subject has been raised on this blog. Now a paper has appeared online which scotches that opinion.

The table shows that nearly half of all 'new chemical entities' (or new drugs) were produced by European companies over a 20 year period from 1982 to 2003.

There are some biases attached to this chart, the main one being that new drugs are assigned to where the company's headquarters are. A good example of how this distorts the table would be Viagra which was discovered in Sandwich, Kent in the UK. But the laboratories where it was discovered were owned by Pfizer, an American drug company, so it goes down as an American discovery.

The big change over the past year has been the amount of money invested in pharmaceutical research, and here American companies have taken the lead: The picture shows that between 1990 and 2000, American funding for pharmaceutical research went from 5.3 billion euros to 23.1 billion euros, while European funding only rose from 7.8 billion to 17.8 billion.

Just as with the American health service, we have to ask whether America is getting value for money. The final graph shows that it is not. The graph shows productivity or innovation proportionate to investment (if you like bangs per buck). You see that for all products productivity in the USA fell by 25% while it rose by 30% in Europe. If we consider only the 'first-in-class' drugs - that means excluding all those me-too medicines - the the discrepancy is the same: a fall in the US of 25% and a rise in Europe of 36%.

There are areas where America excels, particularly biotechnology, but if the question is asked where would the world be without American innovation, the answer is plain.

Thursday, September 03, 2009

Here is an update on my health. The line infection has abated and I have stopped the antibiotics. The dressing over the cut they made when they removed my line should be coming off tomorrow. I can stop the low molecular weight heparin injections at the end of the week. I have already had my loading dose of warfarin; blood test on Friday.

The peripheral neuropathy is still a problem and although I am no longer fainting my blood pressure is normal without my anti-hypertension drugs, which probably means that I have an autonomic neuropathy. My feeling of bloating is still there, though mostly better than it was.

My biggest worry is weight gain. I have put on 5 pounds in the past week. However, I went for the same walk today that I went for two weeks ago. Last time I was breathless just crossing the road, but today I was out for 30 minutes without getting breathless at all. I think it is time I started going to the gym to build up my strength.

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About Me

Born in Worcester, England 1943; school at Farnborough, Hampshire 1954-62; University 1962-7 and junior doctor posts 1967-74 in Bristol; Consultant Haematologist Bournemouth 1974-2003; Professor of Immunohaematology Southampton 1986 to present. Honorary Consultant Haematologist Kings College Hospital, London, 2004-present. After 5 years of working part time researching, writing, reviewing, editing, speaking, sitting on committees, advising, answering questions and thinking, I now think of myself as fully retired apart from my role as Editor in Chief of the medical journal Leukemia Research. I was awarded the Binet-Rai medal for outstanding research in CLL in 2002 and this has been my most sucessful area of research, but I have also made important contributions in the fields of apheresis, stem cell transplantation, myeloma, myelodysplastic syndrome, antibody therapy, cytokine therapy and DNA vaccines. I was once mascot for Aldershot Town Football. Club. Married to Diane for 44 years. Four children, Karen, Richard, Angela and David.